As the opioid epidemic sweeps through rural America, an ever-greater number of drug-dependent newborns are straining hospital neonatal units and draining precious medical resources.The problem has grown more quickly than realized and shows no signs of abating, researchers reported on Monday. Their study, published in JAMA Pediatrics, concludes for the first time that the increase in drug-dependent newborns has been disproportionately larger in rural areas.The rising rates are due largely to widening use of opioids among pregnant women, the researchers found.From 2004 to 2013, the proportion of newborns born dependent on drugs increased nearly sevenfold in hospitals in rural counties, to 7.5 per 1,000 from 1.2 per 1,000. By contrast, the uptick among urban infants was nearly fourfold, to 4.8 per 1,000 from 1.4 per 1,000.“The problem is accelerating in rural areas to a greater degree than in urban areas,” said Dr. Veeral Tolia, a neonatologist who works at Baylor University Medical Center in Dallas and was not involved in the new report.Other recent studies have underscored the breadth of the problem. The hospital costs associated with treating addicted newborns rose to $1.5 billion in 2013, from $732 million in 2009, according to a study in the Journal of Perinatology.Some neonatal intensive care units, called NICUs, now devote 10 percent of their hours to caring for infants who have withdrawal symptoms.Hospitals in the eye of this storm are commonly underresourced, experts said.“Typically, rural hospitals that deliver babies have traditionally focused on the lower-risk population in areas they serve,” said Dr. Alison V. Holmes, an associate professor of pediatrics at Geisel School of Medicine at Dartmouth.“But when you’re getting to a point of having a substantial proportion of mothers taking opioids and babies at risk for opioid withdrawal, it becomes a strain on the regional system.”Using data from 2012 and 2013, a recent federal study found states like West Virginia, Maine and Vermont had particularly high rates of what is known as neonatal abstinence syndrome. It includes such symptoms as irritability, breathing problems, seizures and difficulties taking a bottle or being breast-fed.In the 1970s, withdrawal symptoms affected mostly babies of heroin-addicted mothers in cities such as Philadelphia and New York, Dr. Tolia said. “What this study shows is this has totally flipped,” he added.Babies may be born with symptoms of withdrawal from any number of drugs, including certain antidepressants or barbiturates, after prolonged use by their mothers during pregnancy. But the new report found that rates of infant drug dependency are rising in tandem with maternal opioid use in particular.

​A syringe in downtown Austin, Ind., in Scott County, epicenter of Indiana's 2015 HIV outbreak, the worst in state history. It was fueled by the opioid epidemic and intravenous drug use. (Christopher Fryer/News and Tribune via AP)Needle-sharing by opiate addicts is placing rural white communities at much greater risk of new HIV infections than ever before, and the United States doesn’t have enough syringe programs in place to address the problem, according to a federal report released Tuesday.Although needle exchange programs have been politically controversial for decades, studies have demonstrated their public health benefits in dramatically reducing the rate of HIV transmission and risk of hepatitis infections among injection drug users without increasing the rate of illegal drug use.The new report by the Centers for Disease Control and Prevention found that use of these programs has increased substantially during the past decade, but most people who inject drugs still don’t always use sterile needles. Sharing needles and syringes is a direct route of transmission for HIV and hepatitis B and C viruses.As a result, decades of progress in reducing HIV spread by dirty needles is being threatened. People who would not have been considered at risk for these infections are now vulnerable, especially white people living in predominantly rural areas of the country, including Appalachia, rural parts of New England and the Ozarks.“The big picture here is that we’ve had a lot of progress reducing HIV infections spread by needles and we’re at risk of stalling or reversing that progress,” said CDC Director Tom Frieden in an interview. As a result of the opioid epidemic, he said, “more people appear to be injecting drugs, more people are sharing needles, and there are more places not covered by syringe service programs.”[DEA slowed enforcement while opioid epidemic grew out of control]For the first time, in 2014, whites who inject drugs had more HIV diagnoses than any other racial or ethnic population in the country, the report said.Needle exchanges not only provide sterile needles and syringes, they can also help people get counseling, disease testing for HIV and hepatitis C, and referrals to places where patients can get treatment. The services are particularly important because people addicted to drugs often may not seek or get medical care.

Indiana Gov. Mike Pence declared a public health emergency in March in response to the HIV epidemic in Scott County. (Michael Conroy/AP)Officials said a 2015 HIV outbreak in Indiana, while Vice President-elect Mike Pence was governor, was a wake-up call that public health’s worst fears could be realized. About 200 people in a county of 24,000 people were diagnosed with HIV infections, making it the worst outbreak in state history, fueled by opioid addiction and needle sharing. Scott County, the epicenter of the outbreak, ranked last out of the state’s 92 counties for poverty, unemployment, and percentage of people who were uninsured.At the time, syringe exchanges were illegal in the state, and Pence was against them.After federal officials warned of the growing epidemic, Pence signed emergency legislation allowing syringe exchanges in the county. He eventually signed statewide legislation that allows needle exchanges, but only if counties ask for permission in light of a public health emergency.Indiana’s outbreak was a “sentinel event,” an indicator of what could happen in more than 200 other communities in 26 states that are at risk for similar outbreaks, Frieden said.Although decisions for syringe service programs are made at state and local levels, there has been intermittent federal funding in recent years. Asked whether the incoming Trump-Pence administration could put that federal funding in jeopardy, Frieden said: “When people look at the data and are faced with the real challenges, they see that these are programs that save lives and save money.”CDC researchers have identified 220 counties most vulnerable to an outbreak of HIV or hepatitis C by analyzing factors including overdose deaths, pharmacy sales of prescription painkillers and unemployment and poverty rates. At an infectious disease conference in New Orleans in October, CDC researchers presented a U.S. map showing those vulnerable counties and the locations of syringe service programs.

The areas in pink show U.S. counties vulnerable to rapid spread of HIV and hepatitis C infection among people who inject drugs. The green areas show syringe service programs, which have been shown to cut those infection risks. (Source: Centers for Disease Control and Prevention)“There’s a striking mismatch,” said John Brooks, a senior medical adviser at CDC’s Division of HIV/AIDS Prevention. The vulnerability assessment “demonstrates what parts of the country we’re very concerned could have an event like Scott County,” he said. In states like Kentucky, Tennessee and West Virginia, more than 40 percent of each state’s counties are considered vulnerable to rapid spread of HIV and new or continuing high numbers of hepatitis C infections among injection drug users.TO CONTINUE-​https://www.washingtonpost.com/news/to-your-health/wp/2016/11/29/white-rural-drug-users-lack-needle-exchange-programs